Obstetric Complications

Question 1

What is placenta accreta?

Answer 1

villi of placenta attach to myometrium, not to desidua basalis

accreta= attaches

Question 2

What is placenta increta?

Answer 2

placental villi invade myometrium

increta = invades

Question 3

What is placenta percreta?

Answer 3

placental villi penetrate through myometrium, may reach bladder

percreta = penetrates

Question 4

Why is placenta accreta, increta or percreta an issue?

Answer 4

deep penetration -> poor separation/retention -> hemorrhage, risk of infection

Question 5

Tx for retained placental tissue?

Answer 5

1. manage blood loss: 2 large bore IV, type and screen (45 mins)

reminder: type = blood type, ABO antigens & RhD antigen

screen = “unexpected” antibodies, especially in patients with multiple transfusions

^{*type and screen only valid for 3 months post delivery, as moms can make new antibodies to fetal antigens during delivery}

Question 6

What is uterine inversion? Tx?

Answer 6

1. ABC,give IV crystalloids _{(aqueous solutionsof mineral salts or other water-soluble molecules ex. NS}), call anesthesia

uterine inversion - medical emergency - most often from pulling too hard when delivering placenta, or due to abnormal implantation. medical emerg - risk of shock/sepsis (vasovagal response -> vasodilation + hypovolemia -> shock)

Tx:

Question 7

how is pre-existing hypertention (in pregnancy) defined?

how is it different from gestational hypertension?

Answer 7

hypertension in pregnancy = HIP

pre-existing: HTN >140/90 prior to 20 weeks gestation and > 7 weeks post partum

gestational: sBP > 140 or dBP>90 after 20 weeks GA in a normotensive woman

risks: primigravida, FHx, DM, renal problems, antiphospholipid syndrome (autoimmune, hypergoagulative due to antiphospholipid antibodies)

Question 8

evaluation of hypertension in pregnancy?

Answer 8

MOM

• body weight
• CNS:
  
  • blurry vision
  • scotomas
  • tremours,irritability
  • hypereflexia
  • headache
• heme: bleeding, petechia (high pressure envir.)
• hepatic: RUQ pain/epigastric pain, nausea
• renal: change in output/colour
• edema

FETUS:

• fetal movement
• fetal growth (U/S)
• fetal HR (NST, Doppler)
• BPP - biophysical profile (U/S)

Question 9

complications of hypertension in pregnancy? tests?

Answer 9

worry about:

• liver and renal dysfunction
• seizure (tonic clonic most likely)
• abruptio placentae
• LV heart failure (high resistance!)
• DIC due to placental factors
• HELLP (hemolysis, elevated liver enzymes, low platelets)
• hemorrhagic stroke
• fetal: IUGR, prematurity, IUFD (fetal demise)

LABS:

CBC

PTT, INR, fibrinogen, d-dimer etc - may need surgery, address DIC, HELLP

liver: ALT, AST, LDH, bili - r/o liver failure, HELLP
kidney: proteinuria, creatinine, uric acid, 24 hr urine - kidney failure

Question 10

what is preeclampsia, how is it different from gestational hypertension/

Answer 10

preeclampsia = gestational hypertension + proteinuria or organ failure

Question 11

management of hypertension in pregnancy?

Answer 11

labetalol (beta blocker) - 100-300 mg PO bid/tid L-à-ß-LOL (alpha/beta antagonist)

nifedipine (Ca++ channel blocker, heart protector + vasodilator) - 30-40 mg PO daily

alpha-methyldopa (sympatholytic, alpha 2 agonist) - 250-500 mg PO tid/qid

cannot do diuretics - reduces blood volume, thus blood flow to baby

cannot do ACE inhibitors - teratogenic

cannot do propanolol - teratogenic

Question 12

management of preeclampsia?

Answer 12

depends on GA & treat of seizures

if stable -admit and follow until 34-36 weekes

if severe, stabilize and deliver

hydralazine (direct arterial vasodilator, short-acting) 5-10 mg IV bolus, labetalol 20-50 mg IV

MgSO4 for seizure prevention (but risk of toxicity)

vitals

Question 13

what is eclampsia? management?

Answer 13

1: ABC

eclampsia - preeclampsia + convulsions or coma

often hyperreflexia present, typically tonic-clonc seizure (60 s +), symptoms of hypertension

Tx:

Question 14

urinary tract infections, etiology and clinical features?

Answer 14

• increased urinary stasis in pregnancy, more so due to progesterone
• most common complication of pregnancy
• must treat even if asymptomatic b/c of increased risk of cystitis, pyelonephritis and preterm labour
• symptoms of cystitis: urgency, dysuria, frequency
• symptoms in pyelonephritis: CVA tenderness, fever, flank pain

Question 15

UTI in pregnancy, how do you investigate and manage?

Answer 15

Labs: urine C&S, urinalysis

if frequent infections, consider cystoscopy and renal fx tests

Tx: #1 - amoxicillin (250-500 mg PO q8h x 7 days)

or nitrofurantoin (100 mg PO bid x 7 days)

do urine samples monthly - recurrence common

if pyelonephritis suspected, hospitalize

Question 16

When is the incidence of venous thromboembolism (VTE) the highest ? (T1/T2/T3…)

Answer 16

equal frequency in all three trimesters and postpartum

in pregnancy: increased factors (II, V, VII, VIII, IX, X, XII, fibrinogen), increased platelet aggregation, increased resistance to protein C, decrease in venous flow in lower extremity by T3, etc -> body prepares to coagulate in labour to avoid hemorrhage

most often in iliofemoral or calf veins, left leg

can lead to spontaneous fetal loss

Question 17

venous thromboembolism, investigations? management?

Answer 17

1 - do baseline CBC, including platelets and aPTT

Labs/tests: doppler for DVT

CXR and V/Q scan or spiral CT to r/o PE

Management:

no warfarin - teratogenic, unfractionated heparin and LMWH ok

Question 18

Define antepartum hemorrhage?

Answer 18

antepartum hemorrhage = bleeding between 20-24 weeks gestation and delivery

Question 19

Name 7+ causes of APH?

Answer 19

Placenta

• placenta previa
• placental abruption
• succenturiate placenta

Uterus

• uterine rupture

Fetus

• vasa previa/velamentous insertion
• birth

Gyne

• cervical polyps
• cervicitis (infection)
• cancer
• vaginal lesions
• (not fibroids b/c they are uterine and cervix is closed)

Question 20

What is velamenous umbilical cord?

Answer 20

Velamentous umbilical cord is characterized by membranous umbilical vessels at the placental insertion site (remainder of length normal). Membranous vessels can arise as aberrant branches of marginally insrted umbilical cord or can connect lobes of bilobed placenta or succenturiate lobe placenta. Due to lack of Wharton’s jelly, these vessels are prone to compression and rupture, especially when at cervical os (ie. vasa previa)

1% singletons, 15% monochorionic twins

Question 21

What is vasa previa? How do you manage it?

Answer 21

Vasa previa - unprotected fetal cord vessels passing over internal cervical os

1. Diagnose: TV U/S with colour Doppler
2. Corticosteroids at 28-32 weeks
3. Hospitalization at 30-32
4. C/S at 35 weeks with a higher LT incision. C/S early because want to prevent natural birth

if already in labour -> immediate delivery

Elective C/S - normal pregnancy - 39 weeks

placenta previa - 37 weeks

vasa previa - 35 weeks b/c fetal vessels very fragiled compared to mom

notice down by 2

Question 22

Risk factors for uterine rupture? Prevalence?

Answer 22

Risk factors:

previous C/S especially if classical, T incision or 1 layer closure, or if previous C/S with unknown incision, trauma

no cervidil - known to increase incidence

oxytocin augmentation is controversial

Incidence:

classical vertical scar - 10% risk of rupture

LT scar - 0.5% risk (1 in 200), can try VBAC

if unknown C/S - repeat rather than deliver vaginally (skin incision does not always mimic uterine incision)

Question 23

Presentation of uterine rupture?

Answer 23

Mom:

• unexplained vaginal bleeding -> hypovolemia, shock (bleeding can also be concealed)
• severe abdominal pain
• sudden cessation of uterine contractions
• “tearing” sensation

Fetus:

• fetal bradycardia or nonreasuring strip
• movement of presenting part higher than before

Immediate laparotomy and delivery, may require hysterectomy

Question 24

Define placental abruption?

Answer 24

Premature separation of normally implanted placenta from the uterine wall before the delivery of the baby

Resulting decidual hemorrhage can cause even more bleeding and shearing

Question 25

Symptoms suggesting abrupted placenta?

Answer 25

1% , stillbirth 1 in 830 **abdominal pain + vaginal bleeding** **revealed in 80%, concealed in 20%** mom: uterine hypertonicity (body tries to deliver b/c at risk) risks: hypovolemia secondary to blood loss DIC renal failure adult respiratory distress syndrome multisystem organ failure baby: tachy, nonreassuring fetal heart rate (detached portion unable to exchange gasses and nutrients) risks: IUGR hypoxemia/asphyxia preterm birth mortality

Question 26

What are common risk factors for placental separation?

Answer 26

narrow vessels: * **hypertension** (pre-existing or gestational) * **cocaine** * **smoking (not EtOH)** anatomic: * **trauma** esp. shearing trauma (MVA) * crowding: high parity or polyhydramnios * eversion * sudden decompression (PROM, PPROM) * **previous Hx of placental abruption**

Question 27

What are management steps for placental abruption?

Answer 27

Essentials: * ABCs * Hx and PEx - no vaginal exam until previa ruled out Baby: * continuous fetal monitoring (if distressed C/S if not, can try for vaginal) * U/S for fetal distress "not really clinically useful except to r/o previa" b/c of bleeding Mom: * CBC, crossmatch, coag profile (r/o anemia, DIC, prepare for transfusion) -\> can then correct shock by IV fluids, RBCs, O2 * **Management expectant - if no fetal distress - can try for normal labour, if distress - C/S** * **"manage expectantly b/c clots from abrupted placenta tend to irritate uterus, so patients go into labour really quickly"** **To deliver vaginally:** **monitor maternal vital signs -r/o ABC + multisystem organ failure + adult resp.distress syndrome** **monitor maternal urine output - r/o hypovolemia+shock+renal damage** **fetal heart rate monitoring - ABC** **CBC and coag profile serially - r/o DIC**

Question 28

Things we're looking for on mom's physical in vaginal bleed?

Answer 28

SFH measurement uterine tenderness uterine tone presence of contractions is bleeding active? colour? amount?

Question 29

What is DIC? What would be expected blood work results?

Answer 29

DIC = disseminated intravascular coagulation - systemic process resulting in both thrombosis and subsequent hemorrhage. Steps: 1. exposure of blood to procoagulants, such as tissue factor (extrinsic pathway) and cancer procoagulants 2. fibrin clot 3. fibrinolysis 4. clotting factors depleted 5. hemorrhage, end-organ damage DIC is a complication of underlying illness - in 1% of hospital admissions, support with platelets and clotting factors. Tx the underlying disease DIC labs: ~ low platelets (used up) ~ low fibrinogen (used up) ~ increased aPTT and INR (clotting factors used up) ~ d-dimers present (fibrin degradation product)

Question 30

Name 3+ maternal complications and 1+ fetal complication of placental abruption?

Answer 30

**Maternal:** hemorrhage -\> shock, death multisystem organ failure DIC renal failure ARDS - adult resp distress syndrome = widespread inflammation in the lungs. While ARDS may be triggered by a trauma or lung infection, it is usually the result of sepsis. ARDS is a disease of alveoli that leads to decreased exchange of oxygen and carbon dioxide (gas exchange). ARDS is associated with several pathologic changes: the release of inflammatory chemicals, breakdown of the cells lining the lung's blood vessels, surfactant loss leading to increased surface tension in the lung, fluid accumulation in the lung, and excessive fibrous connective tissue formation. Mortality 20-50% also Sheehan's, Couvelaire uterus (bruised) **Fetal:** intrauterine fetal demise hypoxia

Question 31

Risk of placental abruption in subsequent pregnancies?

Answer 31

5-17% after abruption in 1 pregnancy 25% after abruption in 2 pregnancies =\> decrease modifiable factors (no smoking, cocaine, hypertension) =\> close follow-up in subsequent pregancies, can give them ASA

Question 32

Name and describe 3 types of placenta previa?

Answer 32

Complete - covers all of internal os Incomplete - partially covers internal os Low-lying - within 2-3 cm of internal os

Question 33

What do you do if placenta previa is suspected?

Answer 33

1. Transvaginal ultrasound to confirm - more accurate than transabdominal (scan at 20 as per usual, than repeat at 32ish to see if previa disappeared 90% resolve due elongation of lower uterine segment) 2. Repeat at 35+ weeks to plan for delivery - know os-placental edge distance * if placental edge \> 20 mm, woman can be offered a trial of labour * if placental edge 0-20 mm away from os - higher C/S although vaginal delivery still possible * any degree of overlap after 35 weeks is an indication for C/S If patient at 32 weeks is still previa: ~ educate abour risk of hemorrhage ~ pelvic rest " nothing in the vagina" - no sex, no vaginal exams ~ present immediately if vaginal bleeding, monitor for a few days in the hospital, if bleeding stops + FHR reassuring, can send home for bedrest, give betametasone \< 34 weeks just in case ~ with anterior placenta previa worry about accreta ~ repeat U/S in 3-4 weeks (35-36 weeks) to plan for labour Labour: C/S at 37-38 weeks (vs 35 with vasa previa) C/S at 36ish if mature lungs C/S if excessive bleeding at anytime if marginal or low-lying can try labour

Question 34

What are risk factors for placenta previa?

Answer 34

1. previous C/S (1-4% after 1, 10% after 4) 2. maternal age \> 35 3. twin pregancy - dichorionic 4. previous Hx of previa 5. fetal anomalities 6. 5-10% of previas are associated with placenta accreta!

Question 35

Name 2 serious maternal complications at the time of delivery for previa?

Answer 35

hemorrhage - severe placenta acreta, increta or percreta with possible hysterectomy - get urology on board in case percreta invades to bladder

Question 36

Who is most at risk of placenta accreta?

Answer 36

women with placenta previa and previous C/S